sensitivity Disp: Inj 3g/1g vial SE: Hemolytic anemia, false + proteinuria Notes: Often used in combo w/ aminoglycosides; penetrates CNS with meningeal irrita- tion; see also ticarcillin Ticlopidine (Ticlid) WARNING: Neutropenia/agranulocytosis, TTP, aplas- tic anemia reported Uses: *↓ risk of thrombotic stroke,* protect grafts status post CABG, diabetic microangiopathy, ischemic heart Dz, DVT prophylaxis, graft pro- phylaxis after renal transplant Action: Plt aggregation inhibitor Dose: 250 mg PO bid w/ food Caution: [B, ?/–], ↑ tox of ASA, anticoagulation, NSAIDs, theo- phylline Contra: Bleeding, hepatic impair, neutropenia, thrombocytopenia Disp: Tabs 250 mg SE: Bleeding, GI upset, rash, ↑ on LFTs Notes: Follow CBC 1st 3 mo Tigecycline (Tygacil) Uses: *Rx complicated skin & soft tissue Infxns, & complicated intraabd Infxns* Action: New class: related to tetracycline; Spectrum: Broad gram (+), gram (–), anaerobic, some mycobacterial; E. coli, Enterococcus faecalis (vanco-susceptible isolates), Staph aureus (meth-susceptible/resistant), Strep (agalactiae, anginosus grp, pyogenes), Citrobacter freundii, Enterobacter cloacae, B. fragilis group, C. perfringens, Peptostreptococcus Dose: Adults. 100 mg, then 50 mg q12h IV over 30–60 min every 12 h Caution: [D, ?] hepatic im- pair, monotherapy w/ intestinal perf, not OK in peds Contra: Component sensitiv- ity Disp: Inj 50 mg vial SE: N/V, inj site Rxn Timolol (Blocadren) WARNING: Exacerbation of ischemic heart Dz w/ abrupt D/C Uses: *HTN & MI* Action: β-adrenergic receptor blocker, β 1 , β 2 Dose: HTN: 10–20 mg bid, up to 60 mg/d. MI: 10 mg bid Caution: [C (1st tri; D if 2nd or 3rd tri), +] Contra: CHF, cardiogenic shock, bradycardia, heart block, COPD, asthma Disp: Tabs 5, 10, 20 mg SE: Sexual dysfunction, arrhythmia, dizzi- ness, fatigue, CHF Timolol, Ophthalmic (Timoptic) Uses: *Glaucoma* Action: β-blocker Dose: 0.25% 1 gt bid; ↓ to daily when controlled; use 0.5% if needed; 1 gtt/d gel Caution: [C (1st tri; D 2nd or 3rd), ?/+] Disp: Soln 0.25/0.5%; Timoptic XE (0.25, 0.5%) gel-forming soln SE: Local irritation Tinidazole (Tindamax) WARNING: Off-label use discouraged (animal carcinogenicity w/ other drugs in class) Uses: Adults/children > 3 y. * Trichomo- niasis & giardiasis; intestinal amebiasis or amebic liver abscess * Action: Antipro- tozoal nitroimidazole; Spectrum: Trichomonas vaginalis, Giardia duodenalis, Entamoeba histolytica Dose: Adults. Trichomoniasis: 2 g PO; Rx partner; Giardia- sis: 2 g PO; Amebiasis: 2 g PO daily × 3; Amebic liver abscess: 2 g PO daily × 3–5; Peds. Trichomoniasis: 50 mg/kg PO, 2 g/day max; Giardiasis: 50 mg/kg PO, 2 g max; Amebiasis: 50 mg/kg PO daily × 3, 2 g/day max; Amebic liver abscess: 50 mg/kg PO daily × 3–5, 2 g/day max; w/ food Caution: [C, D in 1st trim; –] May be cross-resistant with metronidazole; Sz/peripheral neuropathy may require D/C; w/ CNS/hepatic impair Contra: Metronidazole allergy, 1st trim PRG, w/ EtOH use Disp: Tabs 250, 500 SE: CNS disturbances; blood dyscrasias, taste disturbances, 202 Ticlopidine N/V, darkens urine Notes: D/C EtOH during & 3 d after Rx; potentiates warfarin & lithium; clearance ↓ w/other drugs; crush & disperse in cherry syrup for peds; re- moved by HD Tinzaparin (Innohep) WARNING: Risk of spinal/epidural hematomas development w/ spinal anesthesia or lumbar puncture Uses: *Rx of DVT w/ or w/o PE* Action: LMW heparin Dose: 175 units/kg SQ daily at least 6 d until war- farin dose stabilized Caution: [B, ?] Pork allergy, active bleeding, mild–moderate renal dysfunction Contra: Allergy to sulfites, heparin, benzyl alcohol, HIT Disp: Inj 20,000 units/mL SE: Bleeding, bruising, thrombocytopenia, inj site pain, ↑ LFTs Notes: Monitor via Anti-Xa levels; no effect on: bleeding time, plt Fxn, PT, aPTT Tioconazole (Vagistat) Uses: *Vaginal fungal Infxns* Action: Topical antifungal Dose: 1 applicatorful intravag hs (single dose) Caution: [C, ?] Contra: Component allergy Disp: Vaginal oint 6.5% SE: Local burning, itching, soreness, polyuria Notes: Insert high into vagina Tiotropium (Spiriva) Uses: Bronchospasm w/ COPD, bronchitis, emphy- sema Action: Synthetic anticholinergic like atropine Dose: 1 cap/d inhaled using HandiHaler, do not use w/ spacer Caution: [C, ?/–] BPH, NAG, MyG, renal impair Contra: Acute bronchospasm Disp: Inhalation Caps 18 mcg SE: URI, xerostomia Notes: Monitor FEV 1 or peak flow Tirofiban (Aggrastat) Uses: *Acute coronary synd* Action: Glycopro- tein IIB/IIIa inhibitor Dose: Initial 0.4 mcg/kg/min for 30 min, followed by 0.1 mcg/kg/min; use in combo w/ heparin; ACS or PCI: 0.4 (g/kg/min IV for 30 min, then 0.1 µg/kg/min (ECC 2005); ↓ in renal insuff Caution: [B, ?/–] Contra: Bleeding, intracranial neoplasm, vascular malformation, stroke/surgery/trauma w/in last 30 d, severe HTN Disp: Inj 50, 250 mcg/mL SE: Bleeding, bradycardia, coronary dissection, pelvic pain, rash Tobramycin (Nebcin) Uses: *Serious gram(–) Infxns* Action: Aminogly- coside; ↓ protein synth. Spectrum: Gram(–) bacteria (including Pseudomonas) Dose: Adults. 1–2.5 mg/kg/dose IV q8–24h. Peds. 2.5 mg/kg/dose IV q8h; ↓ w/ renal insuff Caution: [C, M] Contra: Aminoglycoside sensitivity Disp: Inj 10, 40 mg/mL SE: Nephrotox & ototox Notes: Follow CrCl & levels; Levels: Peak: 30 min after inf; Trough < 0.5 h before next dose; Therapeutic: Peak 5–8 mcg/mL, Trough < 2 mcg/mL; Toxic Peak > 12 mcg/mL; 1 ⁄2 life: 2 h Tobramycin Ophthalmic (AKTob, Tobrex) Uses: *Ocular bacterial Infxns* Action: Aminoglycoside Dose: 1–2 gtt q4h; oint bid–tid; if severe, use oint q3–4h, or 2 gtt q30–60 min, then less frequently Caution: [C, M] Contra: Amino- glycoside sensitivity Disp: Oint & soln tobramycin 0.3% SE: Ocular irritation Tobramycin & Dexamethasone Ophthalmic (TobraDex) Uses: *Ocular bacterial Infxns associated w/ significant inflammation* Action: Antibiotic w/ anti-inflammatory Dose: 0.3% oint apply q3–8h or soln 0.3% apply 1–2 gtt q1–4h Caution: [C, M] Contra: Aminoglycoside sensitivity Disp: Oint & Tobramycin & Dexamethasone Ophthalmic 203 susp 2.5, 5 & 10 mL tobramycin 0.3% & dexamethasone 0.1% SE: Local irrita- tion/edema Notes: Use under ophthalmologist’s direction Tolazamide (Tolinase) Uses: *Type 2 DM* Action: Sulfonylurea; ↑ pan- creatic insulin release; ↑ peripheral insulin sensitivity; ↓ hepatic glucose output Dose: 100–500 mg/d (no benefit > 1 g/d) Caution: [C, +/–] Elderly, hepatic or renal impair Disp: Tabs 100, 250, 500 mg SE: HA, dizziness, GI upset, rash, hy- perglycemia, photosens, blood dyscrasias Tolazoline (Priscoline) Uses: *Peripheral vasospastic disorders* Action: Competitively blocks α-adrenergic receptors Dose: Adults. 10–50 mg IM/IV/SQ qid. Neonates. 1–2 mg/kg IV over 10–15 min, then 1–2 mg/kg/h (adjust w/ ↓ renal Fxn) Caution: Avoid alcohol, w/CAD, renal impairment, CVA, PUD, ↓ BP [C, ?] Contra: CAD Disp: Inj 25 mg/mL SE: ↓ BP, peripheral vasodilation, tachycardia, arrhythmias, GI upset & bleeding, blood dyscrasias, renal failure Tolbutamide (Orinase) Uses: *Type 2 DM* Action: Sulfonylurea; ↑ pancreatic insulin release; ↑ peripheral insulin sensitivity; ↓ hepatic glucose output Dose: 500–1000 mg bid; 3 gm/day max; ↓ in hepatic failure Caution: [C, +] Con- tra: Sulfonylurea sensitivity Disp: Tabs 250, 500 mg SE: HA, dizziness, GI upset, rash, photosens, blood dyscrasias, hypoglycemia, heartburn Tolcapone (Tasmar) WARNING: Cases of fulminant liver failure result- ing in death have occurred Uses: *Adjunct to carbidopa/levodopa in Parkinson Dz* Action: Catechol-O-methyltransferase inhibitor slows levodopa metabolism Dose: 100 mg PO TID w/ first daily levodopa/carbidopa dose, then dose 6 & 12 h later; ↓ /w renal impair Caution: [C, ?] Contra: Hepatic impair; w/nonselective MAOI Disp: Tablets 100 mg, 200 mg SE: Constipation, xerostomia, vivid dreams, hallucinations, anorexia, N/D, orthostasis, liver failure, Rhabdomyolysis Notes: Do not abruptly D/C or ↓ dose; monitor LFTs Tolmetin (Tolectin) WARNING: May ↑ risk of cardiovascular events & GI bleeding Uses: *Arthritis & pain* Action: NSAID; ↓ prostaglandins Dose: 200–600 mg PO tid; 2000 mg/d max Caution: [C (D in 3rd tri or near term), +] Contra: NSAID or ASA sensitivity; use for pain post CABG Disp: Tabs 200, 600 mg; caps 400 mg SE: Dizziness, rash, GI upset, edema, GI bleeding, renal failure Tolnaftate (Tinactin) [OTC] Uses: *Tinea pedis, cruris, corporis, manus, versicolor* Action: Topical antifungal Dose: Apply to area bid for 2–4 wk Caution: [C, ?] Contra: Nail & scalp Infxns Disp: OTC 1% liq; gel; powder; topi- cal cream; ointment, powder, spray soln SE: Local irritation Notes: Avoid ocular contact, Infxn should improve in 7–10 d Tolterodine (Detrol, Detrol LA) Uses: *OAB (frequency, urgency, in- continence)* Action: Anticholinergic Dose: Detrol 1–2 mg PO bid; Detrol LA 2–4 mg/d Caution: [C, ?/–] w/ CYP2D6 & 3A3/4 inhibitor (Table 11) Contra: Uri- nary retention, gastric retention, or uncontrolled NAG Disp: Tabs 1, 2 mg; Detrol LA tabs 2, 4 mg SE: Xerostomia, blurred vision, headache, constipation Notes: LA form may see “intact” pill in stool 204 Tolazamide Topiramate (Topamax) Uses: *Adjunctive Rx for complex partial Szs & tonic–clonic Szs,* bipolar disorder, neuropathic pain, migraine prophylaxis Ac- tion: Anticonvulsant Dose: Adults. Seizures: Total dose 400 mg/d; see insert for 8- wk titration schedule. Migraine prophylaxis: titrate 100 m/d total Peds 2–16 y: Initial, 1–3 mg/kg/d PO qhs; titrate per insert to 5–9 mg/kg/d; ↓ w/ renal impair Caution: [C, ?/–] Contra: Component allergy Disp: Tabs 25, 50, 100, 200 mg; caps sprinkles 15, 25, 50 mg SE: Wgt loss, memory impair, metabolic acidosis, kidney stones, fatigue, dizziness, psychomotor slowing, paresthesias, GI upset, tremor, nystagmus, acute glaucoma requiring D/C Notes: Metabolic acidosis re- sponsive to ↓ dose or D/C; D/C w/taper Topotecan (Hycamtin) WARNING: Chemo precautions, for use by physicians familiar with chemotherapeutic agents, BM suppression possible Uses: *Ovarian CA (cisplatin-refractory), cervical Ca, NSCLC*, sarcoma, ped non-small-cell lung CA Action: Topoisomerase I inhibitor; ↓ DNA synth Dose: 1.5 mg/m 2 /d as a 1-h IV inf × 5 days, repeat q3wk; ↓ w/renal impair Caution: [D, –] Contra: PRG, breast-feeding Disp: Inj 4-mg vials SE: ↓ BM, N/V/D, drug fever, skin rash Torsemide (Demadex) Uses: *Edema, HTN, CHF, & hepatic cirrhosis* Action: Loop diuretic; ↓ reabsorption of Na + & Cl – in ascending loop of Henle & distal tubule Dose: 5–20 mg/d PO or IV; 200 mg/day max Caution: [B, ?] Contra: Sulfonylurea sensitivity Disp: Tabs 5, 10, 20, 100 mg; inj 10 mg/mL SE: Orthosta- tic ↓ BP, HA, dizziness, photosens, electrolyte imbalance, blurred vision, renal im- pair Notes: 20 mg torsemide = 40 mg furosemide Tramadol (Ultram, Ultram ER) Uses: *Moderate–severe pain* Action: Centrally acting analgesic Dose: Adults. 50–100 mg PO q4–6h PRN, start 25 mg PO qam, ↑ Q3d to 25 mg PO QID; ↑ 50 mg Q3D, 400 mg/d max (300 mg if > 75 yr); ER 100–300 mg PO daily Peds. 0.5–1 mg/kg PO q 4–6h PRN; ↓ w/ renal in- suff Caution: [C, ?/–] Contra: Opioid dependency; w/MAOIs; sensitivity to codeine Disp: Tabs 50 mg; ER 10, 20, 30 mg SE: Dizziness, HA, somnolence, GI upset, resp depression, anaphylaxis Notes: ↓ Sz threshold; tolerance/dependence may develop Tramadol/Acetaminophen (Ultracet) Uses: *Short-term Rx acute pain (< 5 d)* Action: Centrally acting analgesic; nonnarcotic analgesic Dose: 2 tabs PO q4–6h PRN; 8 tabs/d max. Elderly/renal impair: Lowest possible dose; 2 tabs q12h max if CrCl < 30 Caution: [C, –] Szs, hepatic/renal impair, or Hx ad- dictive tendencies Contra: Acute intox Disp: Tab 37.5 mg tramadol/325 mg APAP SE: SSRIs, TCAs, opioids, MAOIs ↑ risk of Szs; dizziness, somnolence, tremor, HA, N/V/D, constipation, xerostomia, liver tox, rash, pruritus, ↑ sweating, physical dependence Notes: Avoid EtOH Trandolapril (Mavik) WARNING: Use in PRG in 2nd/3rd tri can result in fetal death Uses: *HTN,* CHF, LVD, post-AMI Action: ACE inhibitor Dose: HTN: 2–4 mg/d; CHF/LVD: 4 mg/d; ↓ w/severe renal/hepatic impair Caution: Trandolapril 205 [D, +] ACE inhibitor sensitivity, angioedema w/ ACE inhibitors Disp: Tabs 1, 2, 4 mg SE: ↓ BP, bradycardia, dizziness, ↑ K + , GI upset, renal impair, cough, an- gioedema Notes: Afro-Americans, min. dose is 2 mg vs 1 mg in Caucasians Trastuzumab (Herceptin) WARNING: Can cause cardiomyopathy and ventricular dysfunction; infusion rxns and pulm toxicity reported Uses: *Met breast CA that overexpress the HER2/neu protein* breast Ca adjuvant, w/ doxoru- bicin, cyclophosphamide, and paclitaxel if pt HER2/neu (+) Action: MoAb; binds human EGF receptor 2 protein (HER2); mediates cellular cytotox Dose: Per proto- col, typical 2 mg/kg/IV/week Caution: [B, ?] CV dysfunction, allergy/inf Rxns Contra: Live vaccines Disp: Inj form 21 mg/mL SE: Anemia, cardiomyopathy, nephrotic synd, pneumonitis Notes: Inf related Rxns minimized w/ aceta- minophen, diphenhydramine & meperidine Trazodone (Desyrel) WARNING: Closely monitor for worsening depres- sion or emergence of suicidality, particularly in pts < 24 yr Uses: *Depression,* hypnotic, augment other antidepressants Action: Antidepressant; ↓ reuptake of serotonin & norepinephrine Dose: Adults & Adolescents. 50–150 mg PO daily–qid; max 600 mg/d. Sleep: 50 mg PO, qhs, PRN Caution: [C, ?/–] Contra: Component allergy Disp: Tabs 50, 100, 150, 300 mg SE: Dizziness, HA, sedation, N, xerostomia, syncope, confusion, tremor, hepatitis, EPS Notes: Takes 1–2 wk for symptom improvement; may interact with CYP3A4 inhibitors to ↑trazodone con- centrations, carbamazepine to ↓ trazodone concentrations Treprostinil Sodium (Remodulin) Uses: *NYHA class II–IV pulm ar- terial HTN* Action: Vasodilation, inhibits plt aggregation Dose: 0.625–1.25 ng/kg/min inj cont inf Caution: [B, ?/–] Contra: Component allergy Disp: 1, 2.5, 5, 10 mg/mL inj SE: Additive effects w/ anticoagulants, antihypertensives; inf site Rxns; D (25%), N (22%), HA (27%) Notes: Initiate in monitored setting; do not D/C or ↓ dose abruptly Tretinoin, Topical [Retinoic Acid] (Retin-A, Avita, Renova, Retin- A Micro) Uses: *Acne vulgaris, sun-damaged skin, wrinkles* (photo aging), some skin CAs Action: Exfoliant retinoic acid derivative Dose: Adults & Peds > 12 y. Apply daily hs (w/ irritation, ↓ frequency). Photoaging: Start w/ 0.025%, ↑ to 0.1% over several mo (apply only q3d if on neck area; dark skin may require bid use) Caution: [C, ?] Contra: Retinoid sensitivity Disp: Cream 0.02, 0.025, 0.05, 0.1%; gel 0.01, 0.025, microformulation gel 0.1, 0.04%; liq 0.05% SE: Avoid sunlight; edema; skin dryness, erythema, scaling, changes in pigmentation, stinging, photosens Triamcinolone (Azmacort) Uses: *Chronic asthma* Actions: Topical steroid Dose: Two inhalations tid–qid or 4 inhal bid Caution: [C, ?] Contra: Component allergy Disp: Aerosol, metered inhaler 100 mcg spray SE: Cough, oral candidiasis Notes: Instruct pts to rinse mouth after use; not for acute asthma Triamcinolone & Nystatin (Mycolog-II) Uses: *Cutaneous candidi- asis* Action: Antifungal & antiinflammatory Dose: Apply lightly to area bid; max 25 mg/d Caution: [C, ?] Contra: Varicella; systemic fungal Infxns Disp: Cream 206 Trastuzumab & oint 15, 30, 60, 120 mg SE: Local irritation, hypertrichosis, pigmentation changes Notes: For short-term use (< 7 d) Triamterene (Dyrenium) Uses: *Edema associated w/ CHF, cirrhosis*Ac- tion: K + -sparing diuretic Dose: Adults. 100–300 mg/24 h PO ÷ daily–bid. Peds. HTN 2–4 mg/kg/d in 1–2 ÷ doses; ↓ w/renal/hepatic impair Caution: [B (manufac- turer; D ed. opinion), ?/–] Contra: ↑ K + , renal impair; caution w/other K + -sparing di- uretics Disp: Caps 50, 100 mg SE: ↓ K + , blood dyscrasias, liver damage, other Rxns Triazolam (Halcion) [C-IV] Uses: *Short-term management of insomnia* Action: Benzodiazepine Dose: 0.125–0.25 mg/d PO hs PRN; ↓ in el- derly Caution: [X, ?/–] Contra: NAG; cirrhosis; concurrent amprenavir, ritonavir, nelfinavir, itraconazole, ketoconazole, nefazodone Disp: Tabs 0.125, 0.25 mg SE: Tachycardia, CP, drowsiness, fatigue, memory impair, GI upset Notes: Additive CNS depression w/ EtOH & other CNS depressants, avoid abrupt D/C, do not pre- scribe > 1 mo supply Triethanolamine (Cerumenex) [OTC] Uses: *Cerumen (ear wax) re- moval* Action: Ceruminolytic agent Dose: Fill ear canal & insert cotton plug; irri- gate w/ H 2 O after 15 min; repeat PRN Caution: [C, ?] Contra: Perforated tympanic membrane, otitis media Disp: Soln 10, 16, 12 mL SE: Local dermatitis, pain, erythema, pruritus Triethylenetriphosphamide (Thio-Tepa, Tespa, TSPA) Uses: *Hodgkin Dz & NHLs; leukemia; breast, ovarian CAs, preparative regimens for al- logeneic & ABMT w/ high doses, intravesical for bladder CA* Action: Polyfunc- tional alkylating agent Dose: 0.5 mg/kg q1–4wk, 6 mg/m 2 IM or IV × 4 d q2–4wk, 15–35 mg/m 2 by cont IV inf over 48 h; 60 mg into the bladder & retained 2 h q1–4wk; 900–125 mg/m 2 in ABMT regimens (highest dose w/o ABMT is 180 mg/m 2 ); 1–10 mg/m 2 (typically 15 mg) IT 1 or 2 X/wk; 0.8 mg/kg in 1–2 L of soln may be instilled intraperitoneally; ↓ in renal failure Caution: [D, –] Contra: Com- ponent allergy Disp: Inj 15, 30 mg SE: ↓ BM, N/V, dizziness, HA, allergy, pares- thesias, alopecia Notes: Intravesical use in bladder Ca infrequent today Trifluoperazine (Stelazine) Uses: *Psychotic disorders* Action: Phe- nothiazine; blocks postsynaptic CNS dopaminergic receptors Dose: Adults. 2–10 mg PO bid. Peds 6–12 y. 1 mg PO daily–bid initial, gradually ↑ to 15 mg/d; ↓ in elderly/debilitated pts Caution: [C, ?/–] Contra: Hx blood dyscrasias; phenoth- iazine sensitivity Disp: Tabs 1, 2, 5, 10 mg; PO conc 10 mg/mL; inj 2 mg/mL SE: Orthostatic ↓ BP, EPS, dizziness, neuroleptic malignant synd, skin discoloration, lowered Sz threshold, photosens, blood dyscrasias Notes: PO conc must be diluted to 60 mL or more prior to administration; requires several weeks for onset of ef- fects Trifluridine Ophthalmic (Viroptic) Uses: *Herpes simplex keratitis & conjunctivitis* Action: Antiviral Dose: 1 gt q2h (max 9 gtt/d); ↓ to 1 gtt q4h after healing begins; Rx up to 21 d Caution: [C, M] Contra: Component allergy Disp: Soln 1% SE: Local burning, stinging Trifluridine Ophthalmic 207 Trihexyphenidyl (Artane) Uses: *Parkinson Dz* Action: Blocks excess acetylcholine at cerebral synapses Dose: 2–5 mg PO daily–qid Caution: [C, +] Contra: NAG, GI obst, MyG, bladder obstructions Disp: Tabs 2, 5 mg; SR caps 5 mg; elixir 2 mg/5 mL SE: Dry skin, constipation, xerostomia, photosens, tachycar- dia, arrhythmias Trimethobenzamide (Tigan) Uses: *N/V* Action: ↓ medullary chemoreceptor trigger zone Dose: Adults. 250 mg PO or 200 mg PR or IM tid–qid PRN. Peds. 20 mg/kg/24 h PO or 15 mg/kg/24 h PR or IM in 3–4 ÷ doses Cau- tion: [C, ?] Contra: Benzocaine sensitivity Disp: Caps 100, 250 mg; supp 100, 200, 300 mg; inj 100 mg/mL SE: Drowsiness, ↓ BP, dizziness; hepatic impair, blood dyscrasias, Szs, parkinsonian-like synd Notes: In the presence of viral In- fxns, may mask emesis or mimic CNS effects of Reye’s synd Trimethoprim (Trimpex, Proloprim) Uses: *UTI due to susceptible gram (+) & gram (–) organisms;* suppression of UTI Action: ↓ dihydrofolate re- ductase. Spectrum: Many gram (+) & (–) except Bacteroides, Branhamella, Bru- cella, Chlamydia, Clostridium, Mycobacterium, Mycoplasma, Nocardia, Neisseria, Pseudomonas, & Treponema Dose: Adults. 100 mg/d PO bid or 200 mg/d PO. Peds. 4 mg/kg/d in 2 ÷ doses; ↓ w/ renal failure Caution: [C, +] Contra: Mega- loblastic anemia due to folate deficiency Disp: Tabs 100, 200 mg; PO soln 50 mg/5 mL SE: Rash, pruritus, megaloblastic anemia, hepatic impair, blood dyscrasias Notes: Take w/ plenty of H 2 O Trimethoprim (TMP)–Sulfamethoxazole (SMX) [Co-Trimoxa- zole] (Bactrim, Septra) Uses: *UTI Rx & prophylaxis, otitis media, sinusi- tis, bronchitis* Action: SMX ↓ synth of dihydrofolic acid;, TMP ↓ dihydrofolate reductase to impair protein synth. Spectrum: Includes Shigella, P. jiroveci (formerly carinii), & Nocardia Infxns, Mycoplasma, Enterobacter sp, Staph, Strep, & more Dose: Adults. 1 DS tab PO bid or 5–20 mg/kg/24 h (based on TMP) IV in 3–4 ÷ doses. P. jiroveci: 15–20 mg/kg/d IV or PO (TMP) in 4 ÷ doses. Nocardia: 10–15 mg/kg/d IV or PO (TMP) in 4 ÷ doses. UTI prophylaxis: 1 PO daily. Peds. 8–10 mg/kg/24 h (TMP) PO ÷ into 2 doses or 3–4 doses IV; do not use in newborns; ↓ in renal failure; maintain hydration Caution: [B (D if near term), +] Contra: Sulfon- amide sensitivity, porphyria, megaloblastic anemia w/ folate deficiency, significant hepatic impair Disp: Regular tabs 80 mg TMP/400 mg SMX; DS tabs 160 mg TMP/800 mg SMX; PO susp 40 mg TMP/200 mg SMX/5 mL; inj 80 mg TMP/ 400 mg SMX/5 mL SE: Allergic skin Rxns, photosens, GI upset, Stevens–Johnson synd, blood dyscrasias, hepatitis Notes: Synergistic combo, interacts w/ warfarin Trimetrexate (Neutrexin) WARNING: Must be used w/ leucovorin to avoid tox Uses: *Moderate–severe PCP* Action: ↓ dihydrofolate reductase Dose: 45 mg/m 2 IV q24h for 21 d; administer w/ leucovorin 20 mg/m 2 IV q6h for 24 d; ↓ in hepatic impair Caution: [D, ?/–] Contra: MTX sensitivity Disp: Inj 25, 200 mg/25 mg/vial SE: Sz, fever, rash, GI upset, anemias, ↑ LFTs, peripheral neu- ropathy, renal impair Notes: Use cytotoxic cautions; inf over 60 min 208 Trihexyphenidyl Triptorelin (Trelstar Depot, Trelstar LA) Uses: *Palliation of ad- vanced PCa* Action: LHRH analog; ↓ GNRH w/ continuous dosing; transient ↑ in LH, FSH, testosterone, & estradiol 7–10 d after first dose; w/ chronic/continu- ous use (usually 2–4 wk), sustained ↓ LH & FSH w/ ↓ testicular & ovarian steroidogenesis similar to surgical castration Dose: 3.75 mg IM monthly or 11.25 mg IM q3mo Caution: [X, N/A] Contra: Not indicated in females Disp: Inj depot 3.75 mg; LA 11.25 mg SE: Dizziness, emotional lability, fatigue, HA, insomnia, HTN, D, V, ED, retention, UTI, pruritus, anemia, inj site pain, musculoskeletal pain, osteoporosis, allergic Rxns Trospium Chloride (Sanctura) Uses: *OAB* Action: Antimuscarinic, antispasmodic Dose: 20 mg PO bid; ↓ w/ renal impair or > 75 y; on empty stom- ach or 1 h ac Caution: [C, ?/–] BOO, GI obst, ulcerative colitis, MyG, renal/he- patic impair Contra: NAG, urinary/gastric retention Disp: Tabs 20 mg SE: Constipation, xerostomia Urokinase (Abbokinase) Uses: *PE, DVT, restore patency to IV catheters* Action: Converts plasminogen to plasmin; causes clot lysis Dose: Adults & Peds. Systemic effect: 4,400 units/kg IV over 10 min, then 4,400–6,000 units/kg/h for 12 h. Restore catheter patency: Inject 5,000 units into catheter & as- pirate up to two doses Caution: [B, +] Contra: Do not use w/in 10 d of surgery, delivery, or organ biopsy; bleeding, CVA, vascular malformation Disp: Powder for inj, 250,000-unit vial SE: Bleeding, ↓ BP, dyspnea, bronchospasm, anaphylaxis, cholesterol embolism Valacyclovir (Valtrex) Uses: *Herpes zoster; genital herpes* Action: Prodrug of acyclovir; ↓ viral DNA replication. Spectrum: Herpes simplex I & II Dose: 1 g PO tid. Genital herpes: 500 mg bid × 7–10 d. Herpes prophylaxis: 500–1000 mg/d; ↓ w/ renal failure Caution: [B, +] Disp: Caplets 500, 1000 mg SE: HA, GI upset, dizziness, pruritus, photophobia Valganciclovir (Valcyte) Uses: *CMV* Action: Ganciclovir prodrug; ↓ viral DNA synth Dose: Induction, 900 mg PO bid w/ food × 21 d, then 900 mg PO daily; ↓ in renal dysfunction Caution: [C, ?/–] Use w/ imipenem/cilastatin, nephrotoxic drugs Contra: Allergy to acyclovir, ganciclovir, valganciclovir; ANC HD < 500/mm 2 ; plt < 25 K; Hgb < 8 g/dL Disp: Tabs 450 mg SE: BM suppres- sion, headache, GI upset Notes: Monitor CBC & Cr Valproic Acid (Depakene, Depakote) Uses: *Rx epilepsy, mania; prophylaxis of migraines,* Alzheimer behavior disorder Action: Anticonvulsant; ↑ availability of GABA Dose: Adults & Peds. Szs: 30–60 mg/kg/24 h PO ÷ tid (after initiation of 10–15 mg/kg/24 h). Mania: 750 mg in 3 ÷ doses, ↑ 60 mg/kg/d max. Migraines: 250 mg bid, ↑ 1000 mg/d max; ↓ w/ hepatic impair Caution: [D, +] Contra: Severe hepatic impair Disp: Caps 250 mg; syrup 250 mg/5 mL SE: Som- nolence, dizziness, GI upset, diplopia, ataxia, rash, thrombocytopenia, hepatitis, pancreatitis, prolonged bleeding times, alopecia, wgt gain, hyperammonemic en- cephalopathy reported in pts w/ urea cycle disorders Notes: Monitor LFTs & Valproic Acid 209 Levels: Trough: just before next dose; Therapeutic: Peak 50–100 mcg/mL; Toxic Trough > 100 mcg/mL; 1 ⁄2 life: 5–20 h; phenobarbital & phenytoin may alter levels Valsartan (Diovan) WARNING: Use during 2nd/3rd tri of PRG can cause fetal harm Uses: HTN, CHF, DN Action: Angiotensin II receptor antagonist Dose: 80–160 mg/d, max 320 mg/day Caution: [C (1st tri; D 2nd & 3rd tri), ?/–] w/ K + -sparing diuretics or K + supls Contra: Severe hepatic impair, biliary cirrho- sis/obst, primary hyperaldosteronism, bilateral RAS Disp: Tabs 40, 80, 160, 320 mg, capsule: 80 mg, 160 mg SE: ↓ BP, dizziness Vancomycin (Vancocin, Vancoled) Uses: *Serious MRSA Infxns; enterococcal Infxns; PO Rx of C. difficile pseudomembranous colitis* Action: ↓ Cell wall synth. Spectrum: Gram(+) bacteria & some anaerobes (includes MRSA, Staphylococcus sp, Enterococcus sp, Streptococcus sp, C. difficile) Dose: Adults. 1 g IV q12h; or 15 mg/kg/dose for colitis 125–500 mg PO q6h. Peds. 40–60 mg/kg/24 h IV in ÷ doses q6–12 h. Neonates. 10–15 mg/kg/dose q12h; ↓ in renal insuff Caution: [C, M] Contra: Component allergy; w/ avoid in Hx hearing loss Disp: Caps 125, 250 mg; powder 250 mg/5 mL, 500 mg/6 mL for PO soln; powder for inj 500 mg, 1000 mg, 10 g/vial SE: Ototoxic & nephrotoxic, GI upset (PO), neutropenia Notes: Not absorbed PO, local effect in gut only; give IV dose slowly (over 1–3 h) to prevent “red-man synd” (flushing of head/neck/upper torso); IV product PO for colitis; Levels: Peak: 1 h after inf; Trough < 0.5 h before next dose; Therapeutic: Peak 30–40 mcg/mL, Trough < 2 mcg/mL; Toxic Peak > 50 mcg/mL, Trough > 15 mcg/mL; 1 ⁄2 life: 6–8 h Vardenafil (Levitra) WARNING: May prolong QT c interval Uses: *ED* Action: PDE5 inhibitor, increases cGMP and NO levels; Relaxes smooth muscles, dilates cavernosal arteries Dose: 10 mg PO 60 min before sexual activity; 2.5 mg if administered w/ CYP3A4 inhibitors (Table 11); max × 1 ≤20 mg Cau- tion: [B, –] W/ CV, hepatic, or renal Dz Contra: Nitrates, ↑ Qtc interval Disp: Tabs 2.5, 5, 10, 20 mg tabs SE: ↓ BP, HA, dyspepsia, priapism hearing loss Notes: Concomitant α-blockers may cause ↓ BP Varenicline (Chantix) Uses: *Smoking cessation* Action: Nicotine re- ceptor antagonist Dose: Adults. 0.5 mg PO daily × 3 d, 0.5 mg bid × 4 d, then 1 mg PO bid for 12 wks total; after meal w/ glass of water Caution: [C,?/–] ↓ dose w/renal impair Disp: Tabs 0.5, 1 mg SE: N, V, insomnia, flatulence, unusual dreams Notes: Slowly ↑ dose to ↓ N; initiate 1 wk before desired smoking cessa- tion date Varicella Virus Vaccine (Varivax) Uses: *Prevent varicella (chicken- pox)* Action: Active immunization; live attenuated virus Dose: Adults & Peds. 0.5 mL SQ, repeat 4–8 wk Caution: [C, M] Contra: Immunocompromise; neomycin-anaphylactoid Rxn, blood dyscrasias; immunosuppressive drugs; avoid PRG for 3 mo after Disp: Powder for inj SE: Mild varicella Infxn; fever, local Rxns, irritability, GI upset Notes: OK for all children & adults who have not had chickenpox 210 Valsartan Vasopressin [Antidiuretic Hormone, ADH] (Pitressin) Uses: *DI; Rx postop abd distension*; adjunct Rx of GI bleeding & esophageal varices; asystole and PEA pulseless VT & VF, adjunct systemic vasopressor (IV drip) Ac- tion: Posterior pituitary hormone, potent GI and peripheral vasoconstrictor Dose: Adults & Peds. DI: 2.5–10 units SQ or IM tid–qid. GI hemorrhage: 0.2–0.4 units/min; ↓ in cirrhosis; caution in vascular Dz. VT/VF: 40 units IVP X1. Vaso- pressor: 0.01–0.04 units/min Caution: [B, +] Contra: Allergy Disp: Inj 20 units/mL SE: HTN, arrhythmias, fever, vertigo, GI upset, tremor Notes: Addition of vasopressor to concurrent norepinephrine or epi infs Vecuronium (Norcuron) Uses: *Skeletal muscle relaxation* Action: Non- depolarizing neuromuscular blocker; onset 2–3 min Dose: Adults & Peds. 0.1–0.2 mg/kg IV bolus (also rapid intubation ECC 2005); maint 0.010–0.015 mg/kg after 25–40 min; additional doses q12–15 min PRN; ↓ in severe renal/hepatic impair Cau- tion: [C, ?] Drug interactions cause ↑ effect (eg, aminoglycosides, tetracycline, suc- cinylcholine) Disp: Powder for inj 10, 20 mg SE: Bradycardia, ↓ BP, itching, rash, tachycardia, CV collapse Notes: Fewer cardiac effects than succinylcholine Venlafaxine (Effexor, Effexor XR) WARNING: Monitor for worsen- ing depression or emergence of suicidality, particularly in ped pts Uses: *Depres- sion, generalized anxiety,* social anxiety disorder; obsessive–compulsive disorder, chronic fatigue synd, ADHD, autism Action: Potentiation of CNS neurotransmitter activity Dose: 75–375 mg/d ÷ into 2–3 equal doses; ↓ w/renal/hepatic impair Cau- tion: [C, ?/–] Contra: MAOIs Disp: Tabs 25, 37.5, 50, 75, 100 mg; ER caps 37.5, 75, 150 mg SE: HTN, ↑ HR, HA, somnolence, GI upset, sexual dysfunction; actu- ates mania or Szs Notes: Avoid EtOH Verapamil (Calan, Isoptin, Verelan) Uses: *Angina, HTN, PSVT, AF, atrial flutter,* migraine prophylaxis, hypertrophic cardiomyopathy, bipolar Dz Action: CCB Dose: Adults. Arrhythmias: 2nd line for PSVT w/ narrow QRS com- plex & adequate BP 2.5–5 mg IV over 1–2 min; repeat 5–10 mg in 15–30 min PRN (30 mg max). Angina: 80–120 mg PO tid, ↑ 480 mg/24 h max. HTN: 80–180 mg PO tid or SR tabs 120–240 mg PO daily to 240 mg bid; 2.5–5.0 mg IV over 1–2 min; repeat 5–10 mg, in 5–30 min PRN; or 5-mg bolus q 15 min (max 30 mg) (ECC 2005) Peds. < 1 y: 0.1–0.2 mg/kg IV over 2 min (may repeat in 30 min). 1–16 y: 0.1–0.3 mg/kg IV over 2 min (may repeat in 30 min); 5 mg max. PO: 1–5 y: 4–8 mg/kg/d in 3 ÷ doses. > 5 y: 80 mg q6–8h; ↓ in renal/hepatic impair Caution: [C, +] Amiodarone/β-blockers/flecainide can cause bradycardia; statins, midazo- lam, tacrolimus, theophylline levels may be ↑; w/ elderly pts Contra: Conduction disorders, cardiogenic shock; beta blocker/thiazide combo, dofetilide, pimozide, ranolazine Disp: Tabs 40, 80, 120 mg; tablets ER 120, 180, 240 mg; tablets ER 24 Hr 180, 240, mg; inj 5 mg/2 mL SE: Gingival hyperplasia, constipation, ↓ BP, bronchospasm, HR or conduction disturbances Vinblastine (Velban, Velbe) WARNING: Chemotherapeutic agent; handle w/ caution Uses: *Hodgkin Dz & NHLs, mycosis fungoides, CAs (testis, Vinblastine 211 [...]... (King) Nortrel 0.5/35 28 (Barr) Nortrel 1/35 21, 28 (Barr) Norinyl 1/35 28 (Watson) Norinyl 1/50 28 (Watson) Ogestrel 28 (Watson) Ortho-Cept 28 (Ortho-McNeil) Ortho-Cyclen 28 (Ortho-McNeil) Ortho-Novum 1/35 28 (Ortho-McNeil) Ortho-Novum 1/50 28 (Ortho-McNeil) Ovcon 35 21, 28 (Warner-Chilcott) Ovcon 50 28 (Warner-Chilcott) Ovral 21, 28 (Wyeth-Ayerst) Portia 28 (Barr) Ethinyl estradiol (30) Ethinyl estradiol... (1.5) 7 in 28 day Norethindrone acetate (1) 7 in 28 day 75 mg FE 7 in 28 day 7 in 28 day 233 Lo/Ovral 21, 28 (Wyeth) Low-Ogestrel 28 (Watson) Microgestin Fe 1/20 21, 28 (Watson) Microgestin Fe 1.5/30 21, 28 (Watson) Mircette 28 (Organon) Modicon 28 (Ortho-McNeil) MonoNessa 28 (Watson) Necon 1/50 28 (Watson) Necon 0.5/35, 28 (Watson) Necon 1/35 28 (Watson) Nordette 21, 28 (King) Nortrel 0.5/35 28 (Barr)... 1 58) Commonly Used Oral Contraceptives (21 = 21 Active Pills; 28 = 21 Active Pills + 7 Placeboa) Monophasics 232 Drug (Manufacturer) Estrogen (mcg) Alesse 21, 28 (Wyeth) Apri 28 (Barr) Aviane 28 (Barr) Brevicon 28 (Watson) Cryselle 28 (Barr) Demulen 1/35 21, 28 (Pfizer) Demulen 1/50 21, 28 (Pfizer) Desogen 28 (Organon) Estrostep 28 (Warner-Chilcott)b FemconFe (Warnen-Chilcott) Junel Fe 1/20, 21, 28. .. (Organon) Estrostep 28 (Warner-Chilcott)b FemconFe (Warnen-Chilcott) Junel Fe 1/20, 21, 28 (Barr) Junel Fe 1.5/30 21, 28 (Barr) Kariva 28 (Barr) Lessina 28 (Barr) Levlen 21, 28 (Berlex) Levlite 28 (Berlex) Levora 28 (Watson) Loestrin Fe 1.5/30 21, 28 (Warner-Chilcott) Loestrin Fe 1/20 21, 28 (Warner-Chilcott) Ethinyl Ethinyl Ethinyl Ethinyl Ethinyl Ethinyl Ethinyl Ethinyl Ethinyl Ethinyl Ethinyl Ethinyl Ethinyl... (Decadron) Hydrocortisone (Solu-Cortef, Hydrocortone) Methylprednisolone acetate (Depo-Medrol) Methylprednisolone succinate (Solu-Medrol) Prednisone (Deltasone) Prednisolone (Delta-Cortef) Relative Equivalent Dose (mg) Relative Mineralocorticoid Activity Duration (h) Route 0.75 25 0 2 36–72 8 12 PO, IM PO, IM 0.75 0 36–72 PO, IV 20 2 8 12 PO, IM, IV 4 0 36–72 PO, IM, IV 4 0 8 12 PO, IM, IV 5 1 12–36 PO... 0.5–1.5 3–5 3–5 3–5 0.25–0.5 0.5 0.5 0.5 2–4 2–4 2.5–5 2–5 5–7 6 8 5 8 6 8 1–2 1–2 1–2 2.5–5 0.5 6–12 6–12 6–12 7–15 7–12 18 24 18 24 14–24 18 24 24 4–6 4–6 4–6 14–24 8 20 No peak 28 36 24– 28 24 0.25–0.5 1–4 24 Ultra Rapid Apidra (glulisine) Humalog (lispro) NovoLog (insulin aspart) Rapid Regular Iletin II Humulin R Novolin R Velosulin Intermediate NPH Iletin II Lente Iletin II Humulin N Novulin L... 223 Copyright © 20 08 by Leonard G Gomella Click here for terms of use TABLE 1 Quick Guide to Dosing of Acetaminophen Based on the Tylenol Product Line 224 Suspensiona Drops and Original Drops 80 mg/0 .8 mL Dropperful Birth–3 mo/ 6–11 lb/ 2.5–5.4 kg 4–11 mo/ 12–17 lb/ 5.5–7.9 kg 12–23 mo/ 18 23 lb/ 8. 0–10.9 kg 2–3 y/24–35 lb/ 11.0–15.9 kg 4–5 y/36–47 lb/ 16.0–21.9 kg Chewablea Tablets 80 mg tabs Suspensiona... Chewablea Tablets 80 mg tabs Suspensiona Liquid and Original Elixir 160 mg/5 mL dpprc (0.4 mL) 1 dpprc (0 .8 mL) tsp 1 dpprc (1.2 mL) tsp 2 dpprc (1.6 mL) 2 tab 1 tsp 3 tab 1 tsp Juniora Strength 160-mg Caplets/ Chewables Regularb Strength 325-mg Caplets/ Tablets Extra Strengthb 500-mg Caplets/ Gelcaps 6 8 y/ 48 59 lb/ 22.0–26.9 kg 9–10 y/60–71 lb/ 27.0–31.9 kg 11 y/72–95 lb/ 32.0–43.9 kg Adults & children ≥... wks × 2 mo then monthly; baseline, periodic ECGs; drink 2 L fluid/day Ziconotide 213 Warfarin (Coumadin) Uses: *Prophylaxis & Rx of PE & DVT, AF w/ em- bolization,* other postop indications Action: ↓ Vitamin K-dependent clotting factors in order: VII-IX-X-II Dose: Adults Titrate, INR 2.0–3.0 for most; mechanical valves INR is 2.5–3.5 ACCP guidelines: 5 mg initial (unless rapid therapeutic INR needed),... CR) [C-IV] Uses: *Short-term Rx of insomnia* Action: Hypnotic agent Dose: 5–10 mg or 12.5 mg CR PO hs PRN; ↓ in elderly (use 6.25 mg CR), hepatic insuff Caution: [B, –] Contra: Breast-feeding Disp: Tabs 5, 10 mg; CR 6.25, 12.5 mg SE: HA, dizziness, drowsiness, N, myalgia Notes: May be habit-forming; CR delivers a rapid then a longer lasting dose Zonisamide (Zonegran) Uses: *Adjunct Rx complex partial . PSVT w/ narrow QRS com- plex & adequate BP 2.5–5 mg IV over 1–2 min; repeat 5–10 mg in 15–30 min PRN (30 mg max). Angina: 80 –120 mg PO tid, ↑ 480 mg/24 h max. HTN: 80 – 180 mg PO tid or SR tabs. max. PO: 1–5 y: 4 8 mg/kg/d in 3 ÷ doses. > 5 y: 80 mg q6–8h; ↓ in renal/hepatic impair Caution: [C, +] Amiodarone/β-blockers/flecainide can cause bradycardia; statins, midazo- lam, tacrolimus,. *Prophylaxis & Rx of PE & DVT, AF w/ em- bolization,* other postop indications Action: ↓ Vitamin K-dependent clotting factors in order: VII-IX-X-II Dose: Adults. Titrate, INR 2.0–3.0 for